Fatality from working with unguarded plant

An alert about the risks associated with operating plant with inadequate guarding, following the death of a worker operating a hay bale pressing machine.



Recently a worker was fatally injured when operating a hay bale pressing machine.

Safety issues

The risk of serious or fatal injuries, from becoming entangled or crushed, exists if a person is able to make contact with moving parts of plant. The risk is increased if a person is working in close proximity to unguarded moving parts.

Access to unguarded parts becomes possible when the guarding on the plant is missing, broken, not secured, has been removed or has not been installed. Plant should not be used until the guarding has been installed, repaired, replaced or retrofitted.

Loose clothing, hair, personal protective equipment or other accessories (eg tool belts) can become entangled, causing a person to be pulled towards the moving parts of the plant.

Ensure guards are fitted to prevent access to any moving parts and nip points (points where rotating or reciprocating parts move toward each other).

Recommended ways to control risks

Identify and control the risk by performing a risk assessment to identify all hazards and assess the adequacy of available control measures on moving and rotating plant. Where an entanglement or crushing risk is present the risk must be controlled.

When controlling risks, priority must be given to the highest level of control. Eliminating the hazard and risk is the highest level of control, followed by reducing the risk through substitution, isolation and engineering controls, then reducing the risk through administrative controls.

Guarding on plant is a type of engineering control. If guarding is used, a permanently fixed or interlocked guarding is to be used. Guarding that can be altered or removed with a tool is a lower order control and can only be implemented if it is not possible to install permanent or interlocked guarding.

Where guarding is used, employers or self-employed persons must ensure that bypassing or disabling of the guarding is as difficult as reasonably possible and does not create a risk in itself.

Control the risks – Permanently prevent access to moving parts

Where access to the area of the plant requiring guarding is not necessary during operation, maintenance or cleaning, the guarding must be a permanently fixed physical barrier. A guard can be permanently fixed by applying a bonding agent, welding or securing with one-way screws. A permanently fixed physical barrier provides the highest level of protection against crushing and entanglement hazards.

Retrofitting guarding

Some plant may not have guarding fitted as standard. Guarding should be retrofitted to prevent access to:

  • hard surfaces moving together (presses)
  • rotating end drums of belt conveyors
  • moving augers or auger conveyors
  • rotating shafts
  • moving parts that do not require regular adjustment
  • machine transmissions, such as pulley and belt drives, chain drives and exposed drive gears
  • any dangerous moving parts or plant

Reduce the risk – Guarding as a control measure

Where guarding is used as a control measure, interlocks form an important part of the guarding to ensure the plant is unable to operate without the guarding correctly in place.

When locking out and isolating to access a moving part for tasks such as servicing, maintenance or cleaning:

  • ensure the following is done prior to removing the guarding:
    • the plant is shut down and methods of activation (eg keys) are removed or use a lock out/tag out system before removing guarding to undertake the tasks
    • allow for plant stored energy to dissipate and run down time for moving components before commencing the work
      • Remember there may be multiple energy sources present that require isolation and dissipation or discharging prior to works commencing.
      • Always test the isolation to ensure it is working as intended before commencing work.
  • inspect guards for damage and repair and replace all guards before re-energising and starting up the plant

Pre-operation inspections

Ensure pre-task inspection of plant occurs and include checking the guarding is installed, and safety systems such as interlocks are operating as required.

Information, instruction, training and supervision

  • Provide employees with information, instruction and training on how to identify hazards associated with moving and rotating plant and how to safely operate plant and how to control risk.
  • Regularly review operating procedures, including lock out and tag out systems when undertaking service, cleaning and maintenance.
  • Provide regular toolbox meetings and maintain adequate warning signs as a constant reminder to employees of the potential hazards associated with plant.

Legal duties

Under the Occupational Health and Safety Act 2004, employers must:

  • so far as is reasonably practicable, provide and maintain a working environment that is safe and without risks to the health of employees and independent contractors
  • provide or maintain plant or systems of work that are safe and without risks to health, so far as is reasonably practicable
  • make arrangements for ensuring, so far as is reasonably practicable, safety and the absence of risks to health in connection with the use, handling, storage or transport of plant
  • provide employees with the necessary information, instruction, training or supervision to enable them to do their work in a way that is safe and without risks to health
  • ensure, so far as is reasonably practicable, that people other than employees are not exposed to risks to their health or safety arising from the employer's conduct
  • consult with employees when identifying or assessing hazards or risks and making decisions about risk control measures

Employers and self-employed persons have additional duties under the Occupational Health and Safety Regulations 2017 associated with the use of plant, including:

  • identifying all hazards associated with the use of plant at the workplace, so far as is reasonably practicable, and
  • controlling risks in accordance with the plant hierarchy of control

Employer duties also apply where some specific risk controls are used, for example, guarding. For more information on these duties see the Plant compliance code.

Further information